Collaboration which is a partnership between the health care worker and patient. This makes both parties experts in their field i.e., the medical care worker is an expert in medical knowledge/science understands the basic medical knowledge whereas the patient is an expert in his disease; he knows his illness more than the medical practitioner could say due to he lived experience, has a personal knowledge of his illness. This contrasts with confrontation where the medical practitioner assumes the expert role and imposes its ideas on the patient.

Evocation: This involves bring out ideas from the patients. Patients’ ideas about the issue facilitate compliance and willingness to change. This is different from the health practitioner imposing their ideas on the patient. The latter is unlikely to have a lasting effect on change because of the lack of originality of the ideas

Autonomy is respect for the patient’s perspective and understanding that change comes from within, and it does not work with authoritarian approach to have a lasting change on an individual. The patient is empowered to take the lead in the process of change based on their resources. This is based on the understanding of the health care worker that there is no right or wrong in the process of change.

The core principles of MI are:

1. Expressing Empathy: Understanding the patient's perspective is crucial. Doctors should listen actively and reflectively, acknowledging the patient's feelings and concerns without judgment. This builds trust and opens dialogue.

2. Developing Discrepancy: This involves helping patients see the gap between their current behaviours and their broader health goals or values. For example, a patient with hypertension who values being around for their grandchildren can be gently guided to see how non-adherence to medication or dietary advice might conflict with that goal.

3. Rolling with Resistance: Resistance is a natural part of the change process. Instead of confronting it head-on, doctors should work with it, using open-ended questions to explore the patient's ambivalence.

4. Supporting Self-Efficacy: This principle focuses on building the patient's confidence that they can change. Doctors should highlight past successes, however small, and emphasize the patient's strengths and abilities.

The effectiveness of MI in sub-Saharan Africa can be enhanced by adapting it to the local context. Here are some key considerations:

- Cultural Sensitivity: Understanding local beliefs, traditions, and social norms is critical. For instance, in some cultures, the influence of family and community is strong, and decisions about health may be collective rather than individual. MI can be adapted to involve family members in the consultation process, respecting the patient’s cultural context.

- Language and Communication: Many patients in sub-Saharan Africa may speak multiple languages or dialects. Effective MI requires that doctors communicate in a language the patient is comfortable with, possibly with the help of interpreters or community health workers who understand the local context.

- Addressing Health Literacy: Health literacy levels vary widely. MI should be adapted to ensure that patients fully understand the information being discussed. This may involve simplifying medical jargon, using visual aids, or providing concrete examples relevant to the patient’s daily life.

- Resource Constraints: Healthcare resources can be limited in sub-Saharan Africa. MI can help optimize the use of these resources by encouraging patients to take an active role in their health, thereby potentially reducing the burden on healthcare systems through improved self-management of chronic conditions.

1. Opening the Conversation: Start with open-ended questions that allow the patient to share their story. For instance, "Can you tell me about how you've been managing your diabetes recently?"

2. Listening and Reflecting: Listen carefully to the patient's responses and reflect their thoughts back to them. For example, "It sounds like you've been struggling to keep up with your medication because of the side effects."

3. Exploring Ambivalence: Use reflective listening to explore any ambivalence the patient may have about changing their behaviour. Ask, "What are some of the things you like about smoking, and what are some things you don’t like about it?"

4. Encouraging Change Talk: Gently guide the conversation toward change by asking questions like, "What do you think it would be like if you were able to stick to the treatment plan?"

5. Setting Goals and Planning: Collaboratively set achievable goals with the patient. For example, "What small step could you take this week to reduce your salt intake?"

Context: A 45-year-old male patient in sub-Saharan Africa has been diagnosed with hypertension but has been inconsistent with taking his medication and following dietary recommendations. The doctor uses Motivational Interviewing (MI) to explore the patient’s ambivalence and encourage behaviour change.

Doctor: Good morning, Mr Ok. It’s good to see you again. How have you been feeling since our last visit? (open question)

Patient: “I’ve been okay, I guess. Just busy with work and family, so it’s hard to keep up with everything.”

Doctor: “I understand that life can get hectic. It sounds like managing your health has been challenging lately. Could you tell me more about how you’ve been handling your medication and diet?” (empathy and evocation of ideas using open questions)

Patient: Well, I try to take the pills, but sometimes I forget. And about the diet, it’s hard to avoid salt because it’s in everything we eat at home.”

Doctor: “It sounds like you’re doing your best, but it’s tough to stay on track with the medication and the dietary changes. What do you think are the biggest challenges for you in sticking to the treatment plan?” (Empathy and exploring ambivalence)

Patient: “The biggest thing is just remembering to take the pills. And with the diet, I don’t want to make a big deal about it at home, you know? My wife cooks for the whole family, and I don’t want to seem like I’m complaining about the food.”

Doctor: “It makes sense that you wouldn’t want to disrupt the family routine, and it’s understandable that remembering to take your medication can be difficult with everything else going on. How important is it for you to manage your blood pressure right now?” (Empathy, respect and evocation of ideas)

Patient: “It’s important, I know that. My father had a stroke when he was about my age, and I don’t want that to happen to me. But it’s just hard to keep up with everything.”

Doctor: “I can hear that you’re concerned about your health, especially with your family history. It’s clear you want to avoid what happened to your father. What do you think might happen if things don’t change, and you continue to miss your medication and struggle with your diet?” (Evocation of ideas)

Patient: “I know it’s not good. I might end up with serious problems, like a stroke or something worse. But sometimes it feels like there’s nothing I can do to change things.”

Doctor: It’s understandable to feel overwhelmed, but it’s also encouraging that you recognize the risks and want to avoid them. What do you think might be one small step you could take to start managing your health better?” (autonomy to the patient)

Patient: Maybe I could try setting an alarm on my phone to remind me to take the pills. As for the diet, I could talk to my wife about reducing the salt a little bit, without making it a big issue.

Doctor: Those sound like very practical steps. Setting an alarm could really help with remembering your medication, and having a gentle conversation with your wife about the salt might be a way to make some small changes without causing disruption. How confident do you feel about trying these changes? (Reflections and autonomy)

Patient: I think I can do it. It’s worth a try, at least.

Doctor: That’s great to hear. Let’s set a goal for the next few weeks. How about you try setting the alarm for your medication and talk to your wife about the diet, and then we’ll check in to see how it’s going at your next appointment? (Setting goals and planning)

Patient: Okay, that sounds good. I’ll give it a shot.

Doctor: I’m confident that these small changes can make a big difference. And remember, I’m here to support you. We’ll work together to keep you on track. Does that sound alright? (Respect)

Patient: Yes, thank you, Doctor. I appreciate your help.

Doctor: You’re very welcome, Mr. Ok. I look forward to hearing how it goes. Take care until we meet again.

In this. example, the doctor uses MI techniques to explore the patient’s ambivalence, highlight the discrepancy between the patient’s current behaviour and his health goals, and support the patient in identifying and committing to small, achievable changes. 3 elements in MI used by collaborating with the patient, evoking ideas and giving the patient autonomy. The conversation is empathetic, collaborative, and patient-centred, which helps build the patient’s motivation to change.